A scoping review of crisis teams managing dementia in older people

Figures & data

Table 1 Included studies and study features

Study reference and type of study	Description of intervention and participants (n)	Description of control group	No of follow-ups and follow-up points	Results control group	Results intervention group	Summary of results
Ratna^Citation17 cohort study	Community orientated old age psychiatry service; providing intensive 24-hour crisis support in the community. Intervention group n=142 Sainsbury et al;^Citation24 Chichester comparison group n=216 Sainsbury et al:^Citation24 Salisbury comparison group n=121	Two retrospective cohorts from the Sainsbury et al^Citation24 study where there was no crisis services	Referral (intervention group n=142; Combined comparison groups n=337) Follow-up 1; 24 months (intervention group n=142; combined comparison groups n=119	Total number of admissions, n, % Combined comparison groups at referral n=132, 39% Combined comparison groups at follow-up n=71, 60% Average length of hospital stay (mean stay in days) Combined comparison groups at follow-up n=101 Maintenance of community residence, n, % Combined comparison groups at follow-up n=42, 35% Mortality rates (%) Combined comparison groups at follow-up 44%	Total number of admissions, n, % At referral n=41, 29%. At follow-up n=48, 34% Average length of hospital stay (mean stay in days) At follow-up n=22 Maintenance of community residence, n, % At follow-up n=69, 49% Mortality rates (%) At follow-up =29%	Reduction in numbers of hospital admissions (at referral follow-up) Reduction in length of hospital stay at follow-up Increase in proportion of people remaining in community at follow-up Improvement in mortality rates at follow-up
Doyle and Varian^Citation18 cohort study	Crisis intervention service operating through Community Mental Health Team (CMHT) Intervention group n=70	The 24-hour community orientated old age psychiatry service as described in Ratna^Citation17	Referral Follow-up 1; 36 months	Refer to Ratna^Citation17	Total number of admissions, n, %: At referral n=22, 31% Maintenance of community residence, n, % At follow-up n=22, 31% Mortality rates (%) At follow-up =30%	No difference at referral compared to Ratna^Citation17 Lower proportion of people remaining in community at follow-up compared to Ratna^Citation17 No difference in mortality rates at follow-up compared to Ratna^Citation17
Richman et al^Citation19 prospective descriptive study	Outreach support team based within a day hospital, providing support in crisis waiting list for an inpatient bed (n=40)	No comparison group	Referral 3 months	Assumption of 100% admission rates for crises	Total number of admissions, n, % Referral n=10, 25% Follow-up n=10, 25%	Reduction in number of hospital admissions
Dibben et al^Citation20 cohort study	Crisis resolution home treatment team (CRHTT) Pre CRHTT (n=65) Post CRHTT (n=102)	6 months pre CRHTT data were collected	Data were collected 6 months pre CRHTT and 6 months post CRHTT	Total number of admission: n=65, 100% Average length of hospital stay; mean (SD) days: 49 (45.62)	Total number of admissions: n=70, 69% Average length of hospital stay: mean (SD) days: 53 (46.40)	Reduction in number of hospital admissions (statistically significant) No difference in length of hospital stay
Ginsburg and Eng^Citation21 cohort study	Mental and Behavioral Health (MBH) team pre, during, and post set up of team	Previous year to set up of MBH	Yearly follow-up for 4 years (2004, 2005, 2006, 2007)	2004, patients served =1,082 Admissions =11 Psychiatric bed days =140	2005, patients served =1,107 Admissions =2 Psychiatric bed days =30 2006, patients served =1,214 Admissions =3 Psychiatric bed days =50 2007, patients served =1,227 Admissions =3 Psychiatric bed days =29	Significant reduction in psychiatric inpatient days from 129.4 days per 1,000 patients per year in 2003 to 23.6 days per 1,000 patients per year in 2007. Significant increase in percentage of enrollees receiving routine mental health services growing from 10.1% of enrollment in 2004 to 24.4% in 2007
Villars et al^Citation22 cohort study	Individualized care plan targeting the problems observed during the hospital stay	Previous year early ER admissions	Early ER rehospitalization 1 month after discharge	Total number of early ER admissions 2007=8.39%	Total number of early ER admissions 2008=8.02% 2009=7.47%	No statistical significant decrease in ER rehospitalization rate at 1 month after discharge. Vocal disruptive behavior is significantly more prevalent in the re admitted population
Johnson et al^Citation23 non-randomized concurrent control treatment outcome trial	Kansas Dementia Crisis Bridge Project Intervention group n=77 Control group =52	Psychiatric hospital with catchment area of rural and suburban residents	Data collected before and during crisis period	5.8% reported psychiatric rehospitalization following hospital discharge	1.2% rehospitalization	Following intervention the Neuropsychiatric Inventory Questionnaire showed a reduction in symptoms p<0.001. Delayed nursing home placement due to the BRIDGE intervention

Figure 1 Consort diagram of included studies.

Table 2 Quality assessment of included studies

Study	1. Did the study address a clearly focused issue?	2. Was the cohort recruited in an acceptable way?	3. Was exposure accurately measured to minimize bias?	4. Was the outcome accurately measured to minimize bias?	5a. Have authors identified all important confounds?	5b. Have they taken account on the confounds in the design/analysis?	6a. Was the follow-up of subjects complete?	6b. Was the follow-up of subjects long enough?	7. What are the results of this study?	8. How precise are the results?	9. Do you believe the results?	10. Can the results be applied to the local population?	11. Do the results of this study fit with other available evidence?	12. What are the implications of this study for practice?	Rating
CASP checklist cohort studies:
Dibben et al^Citation20	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Admissions reduced by 31% General trend for greater satisfaction in carers and service users No difference in involuntary admissions No odds ratios	Quite	Yes	Yes within reason – all health care contexts are different	Yes	Recommendation of use of CRHTT for older people	+
Ginsburg and Eng^Citation21	Yes	Yes	Yes	Yes	No mention of what common mental disorders are experienced Number of ppts with dementia not reported	No	Yes	Yes	Increased access to mental health services Reduction in admissions and psychiatric bed days High staff satisfaction with treatment	Not very	Yes	Potentially, in supported living environments	Not a lot of other evidence is discussed in relation to the findings	Mental health professionals should be a part of integrated living teams	0
Doyle and Varian^Citation18	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Patients in long stay hospital beds similar for both groups Both services good at predicting when hospitalization needed and mobilizing support to prevent further admissions More people in residential care in office hours group – although more residential care also available in this group	Good	Yes	Yes	Yes	Crisis teams operating within office hours can be as effective as 24-hour teams	++
Richman et al^Citation19	Yes	Yes	Yes	Yes	No control group identified	No control group	Yes	Yes	30 admissions to inpatient psychiatric care were avoided through the establishment of this team.	Quite	Yes	Yes in areas where CMHT exists but domiciliary crisis services do not	Yes	This kind of intervention may reduce admission to inpatient psychiatric care	0
Ratna^Citation17	Yes	Yes	Yes	Not known	Yes	Yes	Yes	Yes	The population seen in crisis was similar to that referred to other services Assessments made in the home are as effective in determining who should go to hospital and who can be managed in the community This model is effective at stabilizing patients to enable care in the community	Good	Yes	Yes – but few areas would be able to support a 24-hour crisis service	Yes	Crisis services are able to support people at home	+
Villars et al^Citation22	Yes	Yes	Yes	Yes	Yes	Analyses have not differentiated between severe and mild dementia	Yes	No	No significant differences in early ER rehospitalization	Quite	Yes	Yes	Yes	This type of intervention was welcomed by families and nurses but did not prevent or reduce rehospitalization	+
Study	1. Did the study address a clearly focused issue?	2. Did the authors use an appropriate method to answer their question?	3. Were the cases recruited in an acceptable way?	4. Were the controls selected in an acceptable way?	5. Was exposure accurately measured to minimize bias?	6a. What confounding factors have the authors accounted for?	6b. Have the authors taken account of the potential confounds in design/analysis?	7. What are the results of this study?	8. How precise are the results?	9. Do you believe the results?	10. Can the results be applied to the local population?	11. Do the results of this study fit with other available evidence?	Rating
CASP checklist case–control studies:
Johnson et al^Citation23	Yes	Yes	Yes	Yes	Yes	Differences between control and intervention groups No reporting of participants family situation	No statistical adjustment	Reduction in NP symptoms, 79% resolution in crisis, less hospital admissions than control group, delayed nursing home placement	Quite – no confidence intervals and no reporting of ppts who declined	Yes	Can be applied in areas where complete lack of services. Not sure how well these findings integrate into UK health system	Yes	+

Abbreviations: CASP, Critical Appraisal Skills Programme Centre; CRHTT, crisis resolution home treatment team; CMHT, community mental health team; ER, emergency room; NP, neuropsychiatric; ppts, patients.

Table 3 Characteristics of survey respondents according to team model

Characteristic	Memory assessment service (%)	Community mental health team (%)	Home treatment team (%)	Total responses for each survey question
Employer type
NHS	3 (75)	19 (100)	20 (95)	44
Local authority	1 (25)	0	0
Social enterprise	0	0	1 (5)
Days of operation
Monday–Friday	3 (100)	15 (94)	1 (5)	39
Monday–Sunday	0	1 (6)	19 (95)
Hours of operation
9:00–17:00	3 (100)	15 (94)	1 (5)	39
Extended eg, 7:00–22:00	0	1 (6)	17 (85)
24 hours	0	0	2 (10)
Eligibility criteria
Yes	3 (100)	7 (70)	16 (94)	30
No	0	3 (30)	1 (6)
Referral/screening process
Yes	3 (100)	10 (100)	16 (94)	30
No	0	0	1 (6)
Pathway/protocol
Yes	1 (33)	4 (44)	9 (60)	27
No	2 (67)	5 (56)	6 (40)

Figure 2 Referral characteristics for each model of team managing crisis in dementia.

Figure 3 Characteristics of teams managing crises in people with dementia.

RatnaLCrisis intervention in psychogeriatrics: a two-year follow-up studyBr J Psychiatry19821412963017139214

 PubMed Web of Science ®Google Scholar

SainsburyPCostainWRGradJThe effects of community service on the referral and admission rates of elderly psychiatric patientsWorld Psychiatric Association SymposiumPsychiatric Disorders in the Aged19652337

 Google Scholar

DoyleHVarianJCrisis intervention in psychogeriatrics: a round-the-clock commitment?Int J Geriatr Psychiatry1994916572

 Web of Science ®Google Scholar

RichmanAWilsonKScallyLEdwardsPWoodJService innovationsPsychiatrist2003279348351

 Google Scholar

DibbenCSaeedHStagiasKKhandakerGMRubinszteinJSCrisis resolution and home treatment teams for older people with mental illnessPsychiatr Bull2008327268270

 Google Scholar

GinsburgIFEngCOn-site mental health services for PACE (Program of All-inclusive Care for the Elderly) centersJ Am Med Dir Assoc200910427728019426945

 PubMed Web of Science ®Google Scholar

VillarsHDupuyCSolerPA follow-up intervention in severely demented patients after discharge from a special Alzheimer acute care unit: impact on early emergency room re-hospitalization rateInt J Geriatr Psychiatry201328111131114023348897

 PubMed Web of Science ®Google Scholar

JohnsonDKNiedensMWilsonJRSwartzendruberLYeagerAJonesKTreatment outcomes of a crisis intervention program for dementia with severe psychiatric complications: the Kansas bridge projectGerontologist201353110211222936530

 PubMed Web of Science ®Google Scholar